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Based on medical record review, review of Emergency Department logs, facility policy review, and interview, the facility failed to provide an appropriate (psychiatric) medical screening examination for one patient (#16); the facility failed to ensure a screening was conducted to determine if an Emergency Medical Condition (EMC) existed necessitating a Medical Screening Exam (MSE) for twenty-six patients (#11, #13, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, and #46) identified on the "Removed From Presentation" log (registered with the receptionist in the lobby of the Emergency Department requesting care and removed from Emergency Department log before being clinically evaluated) for the time frame of February 1, 2011 through August 31, 2011; and the facility failed to provide stabilizing treatment prior to discharge for one patient (#16). This deficient practice affected 28 of forty-six patients who presented to the hospital.

Refer to A - 2406
Refer to A - 2407
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Based on medical record review, review of Emergency Department logs, facility policy review, and interviews, the facility failed to provide an appropriate (psychiatric) medical screening examination for one patient (#16); and the facility failed to ensure a screening was conducted to determine if an Emergency Medical Condition (EMC) existed necessitating a Medical Screening Exam (MSE) for twenty-six patients (#11, #13, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, and #46) identified on the "Removed From Presentation" log (registered with the receptionist in the lobby of the Emergency Department requesting care and removed from Emergency Department log before being clinically evaluated) for the time frame of February 1, 2011 through August 31, 2011, of forty-six patients reviewed.

The findings included:

1. Medical record review revealed Patient #16 was admitted to the facility's Emergency Room (ER) August 6, 2011. Medical record review of the ER physician's documentation dated August 6, 2011, at 7:40 p.m., revealed " ...presented to the Emergency Department...Chief Complaint - PSYCHIATRIC...History obtained from: patient, Emergency Medical Services (EMS) ...symptoms are present but decreased ...(spouse) call pd (police department) because pt (patient) had destoryed (destroyed) house because (patient) was mad at (spouse)...EMS was called to house for domestic violence...(spouse) states pt has mental health hx (history) and was using drugs...pt smells of etoh (alcohol) ..."

Medical record review of ER nurse's documentation dated August 6, 2011, revealed, "Patient assigned to room 11. Patient arrived in room and ambulatory (able to walk). Patient moved to room at (7:31 p.m.)..." Medical record review of ER nurse's documentation revealed, " ...reassessed at (8:07 p.m.). no distress noted...was reassessed at (8:38 p.m.). look in room pt (patient) gone..." On August 6, 2011, at 9:59 p.m., patient #16 was returned to the ER by the local police.

Medical record review of ER physician's documentation dated August 6, 2011, revealed, " ...Chief Complaint/History of Present Illness: ...presented to the Emergency Department at (9:56 p.m.) by POLICE ...Chief Complaint - PSYCHIATRIC...History obtained from: patient. Onset of symptoms was immediately prior to arrival at the Emergency Department. Symptoms are present now...anxiety...PD (police department) found pt and returned (patient ) to the ed (Emergency Department...Denies alcohol use. Denies illicit drug use ...pt smells like etoh (alcohol) ..."

Medical record review of ER physician documentation dated August 7, 2011, at 12:30 a.m., revealed, "Note: while waiting for labs to clear pt (patient) medical pt eloped. PD (police department) was notified."Medical record review of ER physician documentation dated August 7, 2011, at 12:31 a.m., revealed, " ...Clinical Impression: 1. Acute Alcohol Intoxication Disposition: Patient has eloped from the emergency department. Condition: Stable."

Medical record review of ER physician documentation dated August 7, 2011, revealed, "Diagnostic Test Results...(12:35 a.m.) ...Abnormal laboratory results: etoh 261 cocaine+ ...Course and Treatment : (1:57 a.m.)...pt's etoh (alcohol) level is high 200's, pt will be monitored while (patient) sobers up, then crt (Crisis Response Team) will evaluate for possible placement..."

Medical record review of laboratory results dated August 6, 2011, at 10:18 p.m., revealed, "Alcohol, Ethyl 261...results equal to or greater than 80...are considered legally intoxicated..." Medical record review of a Urine Drug Screen dated August 7, 2011, at 12:36 a.m., revealed, "...Cocaine...Positive (Normal Range Negative)."

Medical record review of ER nurse's documentation revealed, " ...(7:01 a.m.)...The problem is thought to be related to the psych system(s)...Waiting psych eval (psychiatric evaluation) ..."

Medical record review of ER physician documentation dated August 7, 2011, at 8:48 a.m., revealed, "Patient has received printed discharge instructions. Discharge plans discussed with patient who verbalized understanding and willingness to comply. Patient agrees to follow up with *DENIES HAVING A, DOCTOR. Patient agrees to return to Emergency Department Immediately if symptoms worsen or fail to improve. Limit alcohol consumption do not use cocaine or other illicit substances return to ER if urge to harm self or other, unable to control anger or delusional."

Medical record review of ER nurse's documentation revealed, " ...08/07/2011 at 8:55 a.m., revealed, "Discharge: Patient left the department ...Patient's disposition is: ...HOME ...IN STABLE CONDITION. DENIES ANY NEEDS ..."

Medical record review revealed no documentation regarding a psychiatric and/or crisis response team evaluation as ordered by the physician or an explanation as to why an assessment was not done.

Interview with Security Employee #1 on September 6, 2011, at 11:47 a.m., in a conference room, revealed security was requested to monitor Patient #16 for violent behavior on August 6, 2011, and Security Employee #1 was assigned to the patient. Continued interview revealed Patient #16 was left unattended in ER room 11 while Security Employee #1 assisted in room 12, and Security Employee #1 stated, "...there was no security present to watch (the) door...When I returned to room 11 the patient was gone...We reviewed camera on time frame when (patient) left. We found (patient) left out the double doors, which need an ID (identification) badge to open them. The physician requested we contact the police to have (patient) retrieved..."

Review of the facility policy Medical Screening Exam, policy #20, dated January 2007, revealed "...To ensure all patients presenting to the Emergency department (ED) receives an appropriate Medical Screening Exam (MSE)..."

Review of the facility policy EMTALA (Emergency Medical Treatment and Active Labor Act) - Medical Screening/Stabilization, policy # G2 A, dated as revised January 2007, revealed "...General requirements...when an individual comes...to the Dedicated Emergency Department of the Hospital and request is made...for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the dedicated Emergency Department and emergency services routinely available in the Dedicated Emergency Department...to determine whether an Emergency Medical Condition exists..."

Telephone interview with the ER physician on September 6, 2011, at 1:20 p.m., revealed laboratory results and a psychiatric examination were required to determine the patient's psychiatric stability, and he stated, "...Psych is not my area of expertise." Continued interview confirmed the facility failed to provide a psychiatric screening examination for Patient #16 on August 6, 2011.


2. Review of the Removed from Presentation log revealed patient #11, a 19 year old (yo), presented to the Emergency Department (ED) lobby receptionist area on August 8, 2011, at 6:18 p.m., requesting care for the Complaint of "Asthma/trouble breathing". Continued review of the log revealed "Comments: called X (times) three". Continued review of the log revealed "Time Removed: 7:20 p.m. (1 hour 2 minutes later)".

Review of the Removed from Presentation log revealed patient #13, a 14 yo, presented to the ED lobby receptionist area on August 23, 2011, at 10:01 p.m., requesting care for the Complaint of "Head Injury". Continued review of the log revealed "Comments: Tired of waiting". Continued review of the log revealed "Time Removed: 10:59 p.m. (57 minutes later)".

Review of the Removed from Presentation log revealed patient #23, a 1 yo, presented to the ED lobby receptionist area on February 2, 2011, at 6:07 p.m., requesting care for the Complaint of "Wheezing, congestion, fever". Continued review of the log revealed "Comments: called x four". Continued review of the log revealed "Time Removed: 7:49 p.m. (42 minutes later)".

Review of the Removed from Presentation log revealed patient #24, a 5 yo, presented to the ED lobby receptionist area on February 9, 2011, at 6:57 p.m., requesting care for the Complaint of "head injury, laceration". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 8:03 p.m. (1 hour 3 minutes later)".

Review of the Removed from Presentation log revealed patient #25, a 34 yo, presented to the ED lobby receptionist area on February 21, 2011, at 12:28 p.m., requesting care for the Complaint of "chest pain". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 1:54 p.m. (1 hour 56 minutes later)".

Review of the Removed from Presentation log revealed patient #26, a 41 yo, presented to the ED lobby receptionist area on February 28, 2011, at 8:21 p.m., requesting care for the Complaint of "post surgical complaint - abd (abdominal) pain". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 9:32 p.m. (1 hour 2 minutes later)".

Review of the Removed from Presentation log revealed patient #27, a 32 yo, presented to the ED lobby receptionist area on March 13, 2011, at 12:06 a.m., requesting care for the Complaint of "abd pains - poss (possible) contractions - 16 wks (weeks) pregnant". Continued review of the log revealed "Comments: tired of waiting - decided to go to (named) hospital - unhappy with prior visit" Continued review of the log revealed "Time Removed: 1:20 a.m. (1 hour 14 minutes later)".

Review of the Removed from Presentation log revealed patient #28, a 45 yo, presented to the ED lobby receptionist area on March 21, 2011, at 2:21 p.m., requesting care for the Complaint of "doesn't want to live any longer". Patient presented with suidal ideation with depression. The patient left and could not be found. Continued review of the log revealed "Comments: called x three - security notified - campus searched." Continued review of the log revealed "Time Removed: 3:11 p.m. (50 minutes later)".

Review of the Removed from Presentation log revealed patient #29, a 19 yo, presented to the ED lobby receptionist area on April 1, 2011, at 11:47 p.m., requesting care for the Complaint of "drug overdose". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 12:16 a.m. (29 minutes later)".

Review of the Removed from Presentation log revealed patient #30, a 1 yo, presented to the ED lobby receptionist area on April 4, 2011, at 5:59 p.m., requesting care for the Complaint of "bump on head". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 7:27 p.m. (1 hour 28 minutes later)".

Review of the Removed from Presentation log revealed patient #31, a 1 yo, presented to the ED lobby receptionist area on February 6, 2011, at 6:54 p.m., requesting care for the Complaint of "fall - head injury". Continued review of the log revealed "Comments: called 7:40 p.m., 7:47 p.m., 7:53 p.m." Continued review of the log revealed "Time Removed: 7:54 p.m. (1 hour later with first call documented as occurring 46 minutes after presentation)".

Review of the Removed from Presentation log revealed patient #32, a 3 yo, presented to the ED lobby receptionist area on April 11, 2011, at 7:03 p.m., requesting care for the Complaint of "fell - head laceration". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 8:09 p.m. (1 hour 6 minutes later)".

Review of the Removed from Presentation log revealed patient #33, a 3 yo, presented to the ED lobby receptionist area on April 17, 2011, at 8:41 p.m., requesting care for the Complaint of "busted lip - head injury - fall". Continued review of the log revealed "Tired of waiting - States going to (named) hospital for higher level of care." Continued review of the log revealed "Time Removed: 8:56 p.m. (15 minutes later)".

Review of the Removed from Presentation log revealed patient #34, a 62 yo, presented to the ED lobby receptionist area on May 1, 2011, at 1:22 p.m., requesting care for the Complaint of "Chest Pain". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 2:06 p.m. (44 minutes later)".

Review of the Removed from Presentation log revealed patient #35, a 20 yo, presented to the ED lobby receptionist area on May 2, 2011, at 1:14 p.m., requesting care for the Complaint of "states been passing out/having seizures". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 2:05 p.m. (50 minutes later)".

Review of the Removed from Presentation log revealed patient #36, a 70 yo, presented to the ED lobby receptionist area on May 3, 2011, at 8:22 p.m., requesting care for the Complaint of "Chest Pain/right side of face". Continued review of the log revealed "Comments: called x three - went to the parking lot looking." Continued review of the log revealed "Time Removed: 9:07 p.m. (45 minutes later)".

Review of the Removed from Presentation log revealed patient #37, a 63 yo, presented to the ED lobby receptionist area on May 12, 2011, at 12:03 p.m., requesting care for the Complaint of "swelling of hands and feet/difficulty breathing". Continued review of the log revealed "Comments: called x three - receptionist said they left." Continued review of the log revealed "Time Removed: 12:38 p.m. (35 minutes later)".

Review of the Removed from Presentation log revealed patient #38, a 58 yo, presented to the ED lobby receptionist area on May 16, 2011, at 6:22 p.m., requesting care for the Complaint of "spitting up blood". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 7:12 p.m. (50 minutes later)".

Review of the Removed from Presentation log revealed patient #39, a 43 yo, presented to the ED lobby receptionist area on May 29, 2011, at 4:32 p.m., requesting care for the Complaint of "left arm pain, blood clot forming". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 5:52 p.m. (1 hour 20 minutes later)".

Review of the Removed from Presentation log revealed patient #40, a 24 yo, presented to the ED lobby receptionist area on May 31, 2011, at 1:51 p.m., requesting care for the Complaint of "states passed out at (named store), 4 months pregnant". Continued review of the log revealed "Comments: Feeling better. Going to see MD (Medical Doctor) Thursday on appointment time (2 days later)". Continued review of the log revealed "Time Removed: 2:14 p.m. (23 minutes later)".

Review of the Removed from Presentation log revealed patient #41, a 34 yo, presented to the ED lobby receptionist area on June 5, 2011, at 11:39 a.m., requesting care for the Complaint of "short of breath". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 1:12 p.m. (1 hour 33 minutes later)".

Review of the Removed from Presentation log revealed patient #42, a 21 yo, presented to the ED lobby receptionist area on June 25, 2011, at 11:42 p.m., requesting care for the Complaint of "abd pain - 8 weeks pregnant". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 12:50 p.m. (1 hour 8 minutes later)".

Review of the Removed from Presentation log revealed patient #43, a 22 yo, presented to the ED lobby receptionist area on July 15, 2011, at 5:55 p.m., requesting care for the Complaint of "Bee sting/R (right) eye swollen/Allergic". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 6:43 p.m. (48 minutes later)".

Review of the Removed from Presentation log revealed patient #44, a 43 yo, presented to the ED lobby receptionist area on July 31, 2011, at 3:09 p.m., requesting care for the Complaint of "chest pain, had a possible seizure". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 4:07 p.m. (58 minutes later)".

Review of the Removed from Presentation log revealed patient #45, a 23 yo, presented to the ED lobby receptionist area on August 20, 2011, at 9:59 p.m., requesting care for the Complaint of "throat starting to close/facial swelling". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 10:26 p.m. (27 minutes later)".

Review of the Removed from Presentation log revealed patient #46, a 48 yo, presented to the ED lobby receptionist area on August 20, 2011, at 9:30 p.m., requesting care for the Complaint of "abd pain/hx (history) of internal bleeding/diarrhea". Continued review of the log revealed "Comments: called x three." Continued review of the log revealed "Time Removed: 10:27 p.m. (57 minutes later)".

Review of the facility policy Emergency Department Registration, SPAM MANUAL Section 3.3, dated revised July 2010, revealed " ...follow a "reasonable" registration procedure; however, a medical screening examination ...will not be delayed ...Emergency Department Staffing/Coverage ...The nursing/clinical staff must be available at all times for patient care ...Triage is the process by which patients are assessed and the acuity of their illness or injury is determined. Triage should be performed promptly ...it is not the same as the Medical Screening Exam; it is the process which determines in which order patients will receive their screening exam ...If the patient leaves the ED without notifying hospital staff, the hospital staff shall document in (EMR) the fact that the patient had presented and the time the staff discovered that the patient had left ..."

Review of the facility policy Triage Assessment of Patients, #17, dated January 2007, revealed " ...To determine patient acuity ...identify severity of illness or injury ...A licensed professional prior to registration will assess every patient arriving to the ED for care ....Registration will notify the nurse, if away from the desk ..."

Review of the facility ER Registration Help Flow Sheet, un-dated, un-numbered, revealed " ...Emergency (communicate this is an Emergency Condition) ...If not breathing or in acute distress call Code Blue ....If not coding, but Emergency Condition (Chest pain, stroke symptoms, short of breath, etc) ...call Team Leader or House Supervisor ...If no answer, utilize triage or any nursing desk and explain and get help with the Emergency situation ..."

Review of the guidance for Reports for Daily ED Morning Flash Meeting, un-dated, un-numbered, revealed " ...Personnel to attend flash meeting - ED Acute Station Physician, Representative from Administration, House Supervisor, ED team leader, ED Assistant Nurse Manager, ED Director ...(listed as #8 item for daily review) Removed from presentation ..."

Interview in the conference room with the Chief Nursing officer on August 2, 2011, at 9:15 a.m., confirmed the patients' conditions listed above as Removed from Presentation presented with complaints which would require an immediate clinical evaluation from the information provided to the registration clerk. Continued interview revealed a clinical staff member would be expected to see the patient immediately to identify if an Emergency condition existed which required immediate care as the receptionist staff are not clinically able to make that kind of determination.

Interview in the conference room with the Patient Access Team Leader of the ED registration staff on August 2, 2011, at 12:50 p.m., confirmed the registration staff were not qualified to determine the patients' conditions listed above and would be expected to immediately notify the ED nurse of the patient's complaint.

Interview in the conference room with the ED Manager Leader on August 6, 2011, at 12:02 a.m., confirmed any patient presenting to the lobby as a walk-in with the complaints listed in the above would require an immediate assessment by the clinical staff in order to determine if their condition required immediate care. Continued interview revealed the registration staff is to call the ED nurse and notify the nurse of the patient's complaint. Continued interview revealed the medical record did not document the complaints listed on the above patients were addressed timely.

Based on medical record review, facility policy review, and interview, the facility failed to provide stabilizing treatment prior to discharge for one patient (#16) of forty-six samples patients.

The findings included:

Medical record review revealed Patient #16 was admitted to the facility's Emergency Room (ER) August 6, 2011. Medical record review of the ER physician's documentation dated August 6, 2011, at 7:40 p.m., revealed " ...presented to the Emergency Department...Chief Complaint - PSYCHIATRIC...History obtained from: patient, Emergency Medical Services (EMS) ...symptoms are present but decreased ...(spouse) call pd (police department) because pt (patient) had destoryed (destroyed) house because (patient) was mad at (spouse)...EMS was called to house for domestic violence...(spouse) states pt has mental health hx (history) and was using drugs...pt smells of etoh (alcohol) ..."

Medical record review of ER nurse's documentation dated August 6, 2011, revealed, "Patient assigned to room 11. Patient arrived in room and ambulatory (able to walk). Patient moved to room at (7:31 p.m.)..." Medical record review of ER nurse's documentation revealed, " ...reassessed at (8:07 p.m.). no distress noted...was reassessed at (8:38 p.m.). look in room pt (patient) gone..." On August 6, 2011, at 9:59 p.m., patient #16 was returned to the ER by the local police.

Medical record review of ER physician's documentation dated August 6, 2011, revealed, " ...Chief Complaint/History of Present Illness: ...presented to the Emergency Department at (9:56 p.m.) by POLICE ...Chief Complaint - PSYCHIATRIC...History obtained from: patient. Onset of symptoms was immediately prior to arrival at the Emergency Department. Symptoms are present now...anxiety...PD (police department) found pt and returned (patient ) to the ed (Emergency Department...Denies alcohol use. Denies illicit drug use ...pt smells like etoh (alcohol) ..."

Medical record review of ER physician documentation dated August 7, 2011, at 12:30 a.m., revealed, "Note: while waiting for labs to clear pt (patient) medical pt eloped. Pd (police department) was notified."Medical record review of ER physician documentation dated August 7, 2011, at 12:31 a.m., revealed, " ...Clinical Impression: 1. Acute Alcohol Intoxication Disposition: Patient has eloped from the emergency department. Condition: Stable."

Medical record review of ER physician documentation dated August 7, 2011, revealed, "Diagnostic Test Results...(12:35 a.m.) ...Abnormal laboratory results: etoh 261 cocaine+ ...Course and Treatment : (1:57 a.m.)...pt's etoh (alcohol) level is high 200's, pt will be monitored while (patient) sobers up, then crt (Crisis Response Team) will evaluate for possible placement..."

Medical record review of laboratory results dated August 6, 2011, at 10:18 p.m., revealed, "Alcohol, Ethyl 261...results equal to or greater than 80...are considered legally intoxicated..." Medical record review of a Urine Drug Screen dated August 7, 2011, at 12:36 a.m., revealed, "...Cocaine...Positive (Normal Range Negative)."

Medical record review of ER nurse's documentation revealed, " ...(7:01 a.m.)...The problem is thought to be related to the psych system(s)...Waiting psych eval (psychiatric evaluation) ..."

Medical record review of ER physician documentation dated August 7, 2011, at 8:48 a.m., revealed, "Patient has received printed discharge instructions. Discharge plans discussed with patient who verbalized understanding and willingness to comply. Patient agrees to follow up with *DENIES HAVING A, DOCTOR. Patient agrees to return to Emergency Department Immediately if symptoms worsen or fail to improve. Limit alcohol consumption do not use cocaine or other illicit substances return to ER if urge to harm self or other, unable to control anger or delusional."

Medical record review of ER nurse's documentation revealed, " ...08/07/2011 at 8:55 a.m., revealed, "Discharge: Patient left the department ...Patient's disposition is: ...HOME ...IN STABLE CONDITION. DENIES ANY NEEDS ..."

Medical record review revealed no documentation regarding a psychiatric and/or crisis response team evaluation or an explanation as to why an assessment was not done.

Interview with Security Employee #1 on September 6, 2011, at 11:47 a.m., in a conference room, revealed security was requested to monitor Patient #16 for violent behavior on August 6, 2011, and Security Employee #1 was assigned to the patient. Continued interview revealed Patient #16 was left unattended in ER room 11 while Security Employee #1 assisted in room 12, and Security Employee #1 stated, "...there was no security present to watch (the) door...When I returned to room 11 the patient was gone...We reviewed camera on time frame when (patient) left. We found (patient) left out the double doors, which need an ID (identification) badge to open them. The physician requested we contact the police to have (patient) retrieved..."

Review of the facility policy Medical Screening Exam, policy #20, dated January 2007, revealed "...To ensure all patients presenting to the Emergancy department (ED) receives an appropriate Medical Screening Exam (MSE)..."

Review of the facility policy EMTALA (Emergency Medical Treatmentand Active Labor Act) - Medical Screening/Stabilization, policy # G2 A, dated as revised January 2007, revealed "...General requirements...when an individual comes...to the Dedicated Emergency Department of the Hospital and request is made...for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the dedicated Emergency Department and emergency services routinely available in the Dedicated Emergency Department...to determine whether an Emergency Medical Condition exists..."

Telephone interview with the ER physician on September 6, 2011, at 1:20 p.m., revealed laboratory results and a psychiatric examination were required to determine the patient's psychiatric stability, and he stated, "...Psych is not my area of expertise." Continued interview confirmed the facility failed to provide the services required to determine the patient's psychiatric stability prior to the patient's elopement from the facility on August 6, 2011.